Jim Cisler was worried. He had driven his wife, Sharon, to Queens North Hawaii Community Hospital in the evening after a routine medical visit raised concerns about her heart. After fighting traffic to get to the Big Island hospital, he learned his wife had suffered a heart attack and needed a stent inserted.

Big Island locator map

But before the surgery could proceed, Cisler said he was told that his Kaiser Permanente insurance wanted him to do the procedure at a facility on Oahu. That’s how Jim found himself sitting in the back of a midnight airlift, Sharon on a gurney in front of him, heading to Kaiser’s Moanalua Medical Center on Oahu. There, she underwent some of the same intake tests she’d already taken on the Big Island. She wouldn’t get into surgery until after 7 a.m.

The delay was frustrating to Cisler, 79. “We were sitting at a hospital that could’ve taken care of her,” he said. He was glad Sharon, 81, was able to get the care she needed, but the process was much more complicated and time-consuming than he expected.

Time-consuming and complicated sums up a lot of Cisler’s feelings about accessing health services on Hawaii Island, where he lives on the Kailapa Hawaiian homestead. He’s happy there, but routinely has conversations with friends about how hard it is to find specialists to address their health problems. About once a quarter, Cisler and his wife find themselves on a plane to Honolulu funded by Kaiser to seek care that isn’t available locally.

Kaiser declined to comment on the Cislers’ case, citing privacy issues, but said most Hawaii Island patients receive care on island, with specialists traveling to the island on a regular basis.

“Decisions about how and where care is administered are based on a number of factors and made by Permanente physicians seeking the best clinical outcomes,” Kaiser spokeswoman Laura Lott said. “In cases when it’s decided to continue care for medically stable patients at Moanalua Medical Center, our members can expect award-winning care and service.”

Claudia Hartz, community health educator at Hawaii Island Community Health Center, helps a patient during an outreach event. The center recently received federal funding to continue much-needed services on the Big Island. Hawaii Island Community Health

Kaiser patients aren’t unique; Cisler is among many patients who routinely must fly to access medical care on Oahu, Hawaii’s main population center. The entire state suffers from a shortage of medical professionals, an issue the health care industry and policymakers have been trying to address for years.

But lack of available health professionals is particularly acute on the neighbor islands, especially Hawaii island, and even when professionals are available there may be insurance or availability limitations that delay access to care.

Policymakers have been paying attention. The University of Hawaii recently received nearly $1 million to launch a new rural health policy research program, which got up and running last month.

Congress also appropriated another $4.6 million to help the Hawaii Island Community Health Center, formerly the West Hawaii Community Health Center before it merged with the Bay Clinic, in east Hawaii island.

More To Be Done

Richard Taaffe, the organization’s executive director, said the money will help fund care for patients who lack insurance, noting that 90% of the patients the center serves are low income.

Jim and Sharon Cisler smile at their home in north Hawaii island. Courtesy: Jim Cisler

A key problem is recruiting staff. Right now Hawaii Island Community Health Center has openings for physicians, nurse practitioners, physician assistants, front desk workers and others. As a community, he said, the Big Island struggles with a lack of specialists including but not limited to rheumatologists, psychiatrists, ear nose and throat specialists and gastroenterologists.

“We’re forcing people to go to Honolulu for services and that requires someone, usually a caretaker, to go with them,” he said, adding the travel forces people to take more time off work. “It can mean that people don’t get care, they delay their care, so there’s a range of impacts.”

Health care providers say a lot more needs to be done beyond funding. Some potential solutions include bolstering existing rural health training programs for physicians and other health professionals; increasing health insurance reimbursement rates; and providing tax relief by eliminating the general excise tax on medical services.

Addressing Hawaii’s housing shortage and lowering the cost of living generally could also help make health care salaries go further.

Physician Kelley Withy has been trying for years to address the problem through her work leading the Hawaii/Pacific Basin Area Health Education Center, where she does annual physician workforce assessments.

Despite lots of efforts — including her own — to improve and expand training in rural areas, she said medical professional shortages haven’t improved since she started in 2010, in part due to the rising cost of living and the high cost of doing business in the state.

“They’re just getting worse. It’s kind of depressing, really,” she said. The most recent assessment found Maui and Hawaii island had the biggest shortages.

Hilton Raethel, President and CEO of Healthcare Association of Hawaii.
Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, says the pandemic worsened Hawaii’s shortage of health care professionals. Cory Lum/Civil Beat/2020

The pandemic hasn’t helped, says Hilton Raethel, chief executive officer of the Healthcare Association of Hawaii that represents the state’s hospitals and other health care facilities.

“We actually went backwards through the pandemic in terms of the adequacy of our health care workforce,” he said, noting that medical professionals retired and left the state. “We have bigger shortages now than what we had back in 2019.”

Nona Wilson, a retired nurse who lives in Volcano, says from her experience, improving recruitment and retention are what’s needed to address the issue. She’s looking forward to seeing how Hawaii’s newly elected Gov. Josh Green, a Big Island emergency room physician, will tackle the problem while in office.

On Wednesday, Green said that as governor he’ll pursue higher Medicaid reimbursement rates to entice more doctors to accept the public health insurance for low-income people. He also wants to get more state and federal funding to repay physician loans to encourage doctors to practice in rural areas like the Big Island and supports changes to Hawaii medical licensing rules to allow more doctors to practice telehealth in the state.

He said he’s motivated by the more than two decades he spent working as an emergency room physician on Hawaii island as well as the need to address health disparities for people in poverty and Native Hawaiians.

“They are dying eight years earlier than other people because of a lack of access to care,” he said. “They are developing chronic diseases 10 years earlier because of a lack of access to care.”

Gov.-elect Josh Green says he’s motivated by his experience as an emergency room physician to take action to try to improve access to health care for Hawaii residents. David Croxford/Civil Beat/2022

Health Care Shortages

Raethal said many rural communities face health care service limitations because there aren’t enough people — and thus patient demand — to justify many specialties.

Hawaii island, Raethal said, is at a particular disadvantage because its communities are so dispersed, adding transportation challenges as well as broadband access challenges to many patients.

The statistics are dire: A 2021 analysis found Hawaii County had the third highest shortage of primary health care professionals in the nation.

A 2022 report found 75% of Hawaii rural hospitals were at risk of closing, the highest of any state.

A July report by Community First found that nearly six in 10 Hawaii patients report delays in accessing health care services, with 34% of Hawaii island residents under the age of 55 describing their delays as significant.

Scott Grosskreutz, a diagnostic radiologist based in Hilo, remembers when he was chief of staff of Hilo Medical Center and his family’s primary care provider retired at age 75. Even though he was well-connected in the medical community, it was hard to find a replacement.

That’s something he has heard a lot over the years, that it can take months to find replacements once your doctor leaves.

“One woman told me they called 18 different medical practices,” he said. “The bottom line is it’s really difficult to find a health care provider even if you have a serious and life threatening medical condition.”

The University of Hawaii’s new rural health program includes three full time staff and one part-time principal investigator. Pictured left to right are Amy Ma, Reinie Gerrits-Goh, Aimee Malia Grace and Chad Wolke. David Croxford/Civil Beat/2022

Lots of Costs

Grosskreutz thinks part of the problem is economics. Hawaii is one of the only states that taxes medical services through the general excise tax, and that plus the high cost of living and low reimbursement rates discourages health care professionals from opening private practices.

He helped write a bill that passed the state Senate to address that, but the measure died. Part of the challenge is that it would have cost the state $200 million in general excise tax revenue, says Bradley Kuo, a nurse who runs a telehealth company and advocated for the measure.

The general excise tax issue is one that Green wants to address as governor, and is also one of many issues that the University of Hawaii’s new rural health program expects to study as part of its mission to shed light on the impacts that government policies have on Hawaii’s health care needs.

Aimee Grace, the program’s principal investigator, said the team’s first priority is to look at federal policies, such as low Medicare reimbursement rates. The Biden administration recently announced that those may fall further.

Cisler thinks more help can’t come soon enough. He’s been looking for an allergist, a gerontologist and an ophthalmologist. He’s been through three urologists — two left and a third died. His optometrist recently quit.

He’s resigned to frequent trips with his wife to Honolulu, but each time must drive 30 miles roundtrip to pick up taxi vouchers to use there.

“I get tired of looking and finding out that I do have to go to Honolulu and the referral is two or three steps,” he said.

Whether it’s tax relief or more money for Hawaii’s medical school, he thinks something needs to change to encourage health professionals to come — and to stay.

“It needs to be made attractive, period,” he said.

Civil Beat’s health coverage is supported by the Atherton Family Foundation, Swayne Family Fund of Hawaii Community Foundation, Cooke Foundation and Papa Ola Lokahi.

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